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Y.Yazdanpanah ) Service des Maladies Infectieuses et Tropicales Hôpital Bichat Claude Bernard Equipe ATIP/Avenir INSERM.

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Presentation on theme: "Y.Yazdanpanah ) Service des Maladies Infectieuses et Tropicales Hôpital Bichat Claude Bernard Equipe ATIP/Avenir INSERM."— Presentation transcript:

1 Y.Yazdanpanah ) Service des Maladies Infectieuses et Tropicales Hôpital Bichat Claude Bernard Equipe ATIP/Avenir INSERM (U1137) : "Modélisation, Aide à la Décision, et Coût-Efficacité en Maladies Infectieuses" Université Paris Diderot: site Bichat Les études de coût-efficacité influencent-elles les recommandations?

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3 Le Touquet, 25/01/07 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings « HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines » « Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. » MMWR September 22, 2006 / 55(RR14);1-17

4 Si pas de test de résistance : 25% des patients = Trt comportant Lopi/r 75% des patients = Trt comportant Efavirenz

5 Il est recommandé de faire un test génotypique de résistance avant l'initiation d'un traitement antirétroviral : –La fréquence d’infection par des virus résistants. –L’impact délétère de la présence de mutations de résistance sur la réponse virologique –L’importance du premier traitement sur l’évolution de la maladie. –Le coût et l’efficacité. Prise en charge médicale des personnes infectées par le VIH; Rapport 2006

6 6 CV < 50 copies/ml à 24 semaines = 78% vs 85% Echappement après 24 semaines = 5.4 vs. 2.5 Coût/année = US$ 9200 vs Ratio Coût-efficacité = US $ /QALY gagné (CE ratios > 3 x PIB/habitant) “Estimated first-year savings, if all eligible U.S. patients start or switch to generic-based ART, are $920 million”

7 “The study should serve as a wake-up call to clinicians who care for people with HIV: The era of generic antiretrovirals in the United States has come.” Would even a small reduction in the efficacy be acceptable? 7 Sherer et al. 2013

8 8 En tenant compte du coût des différentes associations disponibles.

9 Goldie et al. N Engl J Med 2006 Supported by the ANRS, NIAID, Doris Duke Charitable Foundation Cost-effectiveness of cART = $ 1180/YLS < 3 x Côte d’Ivoire GDP/capita (708 $) = “cost-effective”

10 d4T vs Tenofovir (cost issue) Using tenofovir as part of first- line ART in India will improve survival, is cost-effective by international standards Clin Infect Dis 2010AIDS 2011

11 Strategies to monitor ART efficacy Lancet 2008 Archives Intern Med 2008 J AIDS 2010 Lancet Infect Dis 2013

12 Interpretation—Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings.

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15 Methods and process for developing the guidelines Mathematical modelling on the impact and cost– effectiveness of earlier ART in various populations and settings 15 The following sources of information were used in developing new recommendations

16 Methods and process for developing the guidelines Mathematical modelling on the impact and cost– effectiveness of earlier ART in various populations and settings An impact assessment Reports on country implementation experiences Consultations with health workers Two global community and civil society consultations Systematic reviews 16 The following sources of information were used in developing new recommendations

17 The proposed recommendations were then considered encompassing the following elements Benefits and risks; Community and health care worker values and preferences; Costs and resource implications; cost- effectiveness; Feasibility and barriers to implementation; equity, Ethics and human rights implications; 17

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19 Interpretation—Earlier ART eligibility is estimated to be very cost-effective in low- and middle-income settings, although these questions should be revisited as further information becomes available. Scaling-up ART should be considered among other high-priority health interventions competing for health budgets.

20 Effectiveness, cost, and cost- effectiveness of new interventions: PreP TasP 20 Strategies that should be considered not one by one but in light of each other Testing

21 Objective Generalised Epidemics in Southern Africa (n =7) Concentrated Epidemics among MSM in the USA (n =4) Concentrated Epidemics among MSM in Peru (n =1) Concentrated Epidemics among People Who Inject Drugs in Ukraine (n =1)

22 Objective It is worth noting that, with the exception of four studies in South Africa [28,30,36,37], research comparing the potential trade-offs of earlier treatment for prevention versus PrEP remains an important gap in the literature that should be addressed, especially in concentrated epidemics

23 23 AIDS 2013 Coverage 80% Coverage 40% of years Effectiveness 70%

24 24 AIDS 2013 Cost per infection averted = $ Cost per infection averted = $ ART delivery cost 600 US$/y PreP delivery cost 252 US$/y

25 The financial consequences of introducing a new technology in a specific setting over the short to medium term : affordability

26 26 AIDS 2013 ART delivery cost 600 US$/y PreP delivery cost 252 US$/y

27 Hépatite C From 2% to 3% of the world population with a chronic HCV 1 350,000 deaths from liver complications per year 2 The most concerned regions are East and Central Asia, North Africa and Middle East Lavanchy D et al, Clin Microbiol Infect WHO, HCV factsheet, Mohd Hanafiah et al, Hepatology 2013

28 28 Key priorities for scaling up HCV treatment and care include: -reducing the cost of current and future treatment; -simplifying the package of care; -identifying opportunities to shift specific tasks to nonspecialists to overcome human resource constraints; Clin Infect Dis 2012

29 Slide, adapted from Pr Gamal Esmat

30 Egypt : highest HCV prevalence in the world (15% vs. <1% in France) –About HCV-infected patients How should we prioritize? 30

31 Elevated ALT levelNormal ALT level F 0F1F2F3F4F 0F1F2F3F4 Biopsy, old guidelines Biopsy, new guidelines

32 Treatment efficacy For F0-F1-F2 patients  SVR=64.9% For F3-F4 patients  SVR=39.6% Gad et al, Liver International, 2008 Treatment efficacy with dual therapy Analyse de sensibilité : Sofosbuvir

33 Effectiveness and cost-effectiveness of immediate vs. delayed treatment of HCV-infected patients in a country with limited resources: the case of Egypt (ANRS 12215) Cost ($)Life expectancy (years)QALY (years)ICER ($/QALY) F1, mean age 36 years at diagnosis Treat immediately if elevated ALT, else wait F27436,4120,7018,32- No treatment9067,0219,9616,95Dominated Wait F29146,5920,7618, ,60 Wait F39942,2520,6217,50Dominated 33 Cost ($)Life expectancy (years)QALY (years)ICER ($/QALY) F4, mean age 43 years at diagnosis No treatment7687,5611,938,95- Treat immediately10549,0413,7610,342058,62 Obach et al. Clin Infect Dis, 2014 Treating F4 patients is cost-effective (ICER<3*GDP = 8500$) Cost-effectiveness analysis -If we do not have enough drugs it is better to treat F4 patients than F0 or F1 patients (in term of life-years saved)

34 General conclusion Impact on Egyptian national treatment guidelines in 2013 –Treatment to patients at stages ≥ F2 Reference for the treatment recommendations in limited settings of WHO 2014 guidelines 56

35 How to optimize HCV treatment impact on life years saved in countries with resources constraints EGYPT 1,2 THAILAND 3-5 CÔTE D’IVOIRE 6-9 Political commitmentYesNo Prevalence14.7%2.2%1.9 to 3.4% Number of patients 4,000,000 (2008) 631,000 (2013) 190,770 (2013) Number of treatments per year45,0001,000*150* Treatment rate1.12%0.16%0.08% HCV genotypesGenotype 4 Genotype 3: 53% Genotype 1: 33% Genotype 6: 10% Genotype 2: 4.4% Genotype 1: 79% Genotype 2: 14% Genotype 5: 7% 40 1 El-Zanaty et al, Egypt Demographic and Health Survey Mohamed et al, J Med Virol Lavanchy, Clin Microbiol Infect 2011 * Experts’ opinion 4 World Health Organization 5 Sievert et al, Liver Int Combe et al, Trans R Soc Trop Med Hyg Hépatites en Afrique, News Abidjan, Kouassi-M Bengue et al, Scientific Research and Essay 2008

36 Results Baseline analysis (pegylated IFN+RBV) 45 Base caseScenario 1Scenario 2Scenario 3 EGYPTSE0SE1SE2SE3 Projected data (2014 and after)F1/F2/F3/F4 Number of patients treated per year45,000 Baseline analysis Total life years saved vs. no treatment1,836,6902,334,5622,428,1662,590,458 Additional total LYS vs. base case-+27.1%+32.2%+41.0%

37 Results Baseline analysis (pegylated IFN+RBV) 46 Base caseScenario 1Scenario 2Scenario 3 THAILANDST0ST1ST2ST3 Projected data (2014 and after)F1/F2/F3/F4 Number of patients treated per year1,000 Baseline analysis Total life years saved vs. no treatment52,86846,82737,91760,964 Additional total LYS vs. base case--11.4%-28.3%+15.3% CÔTE D’IVOIRESC0SC1SC2SC3 Number of patients treated per year150 Baseline analysis Total life years saved vs. no treatment10,8119,8947,74712,001 Additional total LYS vs. base case--8.5%-28.3%+11.0%

38 38 Conclusions What economic evaluation is: –a means for evaluating the economic impact of clinical decisions –quantitative analysis for qualitative insight What Economic Evaluation is Not: “The answer” 38

39 39 One component useful for clinical policy development alongside with other issues including fairness, ethics, and political concerns 39 Economic evaluation

40 40 Inserm, Avenir team « Decision Sciences in Infectious Disease Prevention, Control and Care »


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